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What is Hypospadias?

Hypospadias is a condition in which the urethra does not develop completely. This results in an opening that is somewhere on the underside of the penis, scrotum, or perineum.

Hypospadias is almost always associated with other defects, including penile curvature (chordee) and an incomplete or hooded foreskin.

Very mild hypospadias may have a few functional implications, but the condition can affect a child's ability to void standing and eventually to have erections satisfactory for intercourse. It is for these reasons, as well as the obvious cosmetic defect, that most parents elect to have hypospadias repaired.

Hypospadias types

The different types of hypospadias are based on the location of the opening of the urethra. Types of hypospadias include:

  • Distal hypospadias: includes glanular, coronal, subcoronal, and midshaft hypospadias.
  • Glanular: Occurs when the opening is lower than it should be but still on the head of the penis. •
  • Coronal: Occurs when the opening is at the bottom of the head of the penis.
  • Subcoronal: Occurs when the opening is located somewhere near the head of the penis.
  • Midshaft: Occurs when the opening is located along the shaft of the penis, close to the middle of the shaft. Proximal hypospadias, which includes proximal shaft, penoscrotal, scrotal, and perineal hypospadias:
  • Proximal shaft: Occurs when the opening is located low on the shaft, but not yet at the level of the scrotum.
  • Penoscrotal: Occurs when the opening is located where the penis and scrotum meet.
  • Scrotal: Occurs when the opening is located anywhere on the front or bottom of the scrotum.
  • Perineal: Occurs when the opening is located in the area behind the scrotum and in front of the anus.

Hypospadias causes

The exact causes of hypospadias are unknown. Although, there are factors that are believed to be involved in its cause.

Causes may include:

  • Certain hormones during pregnancy
  • Fertility treatments
  • Mother's age and weight
  • Hypospadias may be inherited in some families when other males are affected

Hypospadias Symptoms

Some boys with mild forms of hypospadias have no symptoms at all. Symptoms may include:

  • Opening of the urethra is at a location other than the tip of the penis
  • Downward curve of the penis (chordee)
  • Hooded appearance of the penis
  • Abnormal or downward pointed urine stream

Diagnosing Hypospadias

Hypospadias is generally diagnosed with a physical exam when a baby is born. Most hypospadias will be easily recognized due to the appearance of the penis and foreskin.

Circumcision is generally not recommended when hypospadias is known as the surgeon may need to use the foreskin tissue as part of hypospadias repair surgery. Occasionally, hypospadias is recognized after circumcision; these are usually the most minor forms. Your pediatrician will determine if a urology referral is necessary. Some boys with mild hypospadias can note more penile curvature after puberty, which warrants evaluation in urology.

Hypospadias Treatment

Repair of hypospadias can take many forms, depending on the severity of the deformity.

The first step of any repair is straightening the penis. Almost all hypospadiac penises will have some degree of curvature that needs to be corrected. Often this can be accomplished simply by "degloving" the penis. This involves making an incision around the skin of the penis just under the coronal groove.

As the skin is separated from the shaft of the penis, tethering bands of tissue are released, straightening the penis. Sometimes this dissection can be carried under the skin of the scrotum and even into the perineum, referred to as a radical mobilization of the urethra, a technique developed by UPMC pediatric urology specialists.

If degloving the penis does not result in sufficient straightening, further treatment will be needed. These treatment options fall into two general categories:

  • Procedures that create tucks on the top side of the penis in order to correct the disproportion between the top and bottom sides. This is generally done for relatively mild curvature.
  • Opening the lining of the erectile part of the penis on its underside, and inserting a graft material, most commonly from skin of the abdominal wall.

A penis with severe curvature that requires grafting on the underside will often be repaired in a staged fashion. The first operation involves straightening the penis as described and transposing most of the foreskin to the underside of the penis for later u se in reconstructing the urethra. Approximately six months later, a second operation is performed to create a urethra from the skin on the underside of the penis.

If the urethral plate can be preserved, most often UPMC specialists will try to use it as a primary repair to the hypospadias. This results in a urethra that is composed completely of tissue that was originally intended to be urethra, rather than using skin or other materials. This technique also gives a very normal functional and cosmetic result.

Repair of severe hypospadias or repair after prior failed surgery might require a "free graft" of tissue to rebuild the urethra. This can be skin from the penis, inner arm, or lining of the mouth. Hospitalization is often required after a free graft repair to allow the graft to heal in place with little movement of the area as possible.

Postsurgical management

After surgery, a tube is left in the reconstructed urethra in all but the simplest cases. This tube is called a "stent", and its purpose is to allow free flow of urine while the tissues are healing. Often there is significant swelling in the penis, and voiding might be difficult for your child.

The tube is most commonly managed simply by allowing it to drain into a diaper. In older children, the tube might be attached to a drainage bag that is emptied periodically.

These tubes are usually attached to the head of the penis with one or two stitches, which need to be cut before the tubes can be removed. The tubes might be in place for as few as two or three days, or as long as two weeks. Any changes in drainage from these tubes, or in their position, should be reported to your doctor immediately.

There often will be a dressing, or bandage, around the penis after hypospadias surgery. Most often, this is clear plastic dressing and is removed at the first postoperative visit in the office. These dressings often will fall off by themselves, and this is not a cause for concern unless the dressing bunches at the base of the penis and acts as a tourniquet. If this occurs, the dressing should be removed, or your physician should be contacted immediately.

Possible complications

Overall, the results of hypospadias repair are excellent. However, it is important to realize that no surgical procedure is perfect and that the results of hypospadias repair cannot be guaranteed.

Nevertheless, in almost every case, these problems can be dealt with to give a very acceptable result. Some complications that may occur with hypospadias repair include:

  • Breakdown of the urethral reconstruction. This is the most common complication. It is usually manifested by a fistula, a small opening between the urethra and the skin. If a fistula should occur, UPMC specialists simply watch it for a period of six months. So, me fistulas will close on their own. Those that do not are repaired in a subsequent surgical procedure that is usually much smaller than the original hpospadias repair. Usually, a fistula does not affect the ultimate functional and cosmetic outcome of the repair.
  • Breakdown of the repair. The head of the penis can reopen, giving a hypospadiac appearance to the penis. Rarely, the entire repair will come apart, requiring a significant follow-up operation.
  • Persistent or recurrent penile curvature.

The goal of hypospadias surgery is to provide a penis that is functionally and cosmetically normal. Whether these goals will be met to your satisfaction depends largely on the original anatomy and the tissue available for reconstruction.

Minor cosmetic defects can be found after hypospadias surgery, but often these will not be noticeable to the casual observer.

Concerns have been raised, especially on the Internet, about long-term sensation and sexual pleasure in men who have undergone hypospadias repair. The best data indicates that difficulties with erection, sensation, or orgasm are very unlikely to result from hypospadias surgery.

Treatment at UPMC

The Department of Pediatric Urology at UPMC Children's Hospital of Pittsburgh has pioneered new and simpler techniques for the repair of hypospadias, with excellent results. Contact us to schedule an appointment, 412-692-4100.